Arbors At Marietta

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure nursing staff planned to administer the appropriate dose of medication, without resident intervention, to prevent a potential overdose. This affected one resident (Resident #104) of one residents reviewed for a medication error. The census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. Record review revealed on 12/24/24 an order was received for Methadone 10 milligrams (mg): Give two tablets by mouth three times a day However the order was discontinued on 12/24/24. On 12/26/24, an order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to thoroughly investigate a potential medication error and the disposition of controlled medications. This affected one resident (#104) of one residents reviewed for a medication error. The facility census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. Record review revealed on 12/24/24 an order was received for Methadone 10 milligrams (mg): Give two tablets by mouth three times a day However the order was discontinued on 12/24/24. On 12/26/24, an order for Methadone 10 mg give two tablets via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility alternative dispute resolution agreements, interview, record review, and policy review, the facility failed to ensure residents understood the agreement they signed. This affected three of three residents reviewed for arbitration agreements (Residents #31, #89, and #178). The facility census was 124. Findings include: 1. Review of the record for Resident #31 revealed an admission date of 01/20/25. Review of a Minimum Data Set (MDS) assessment completed 01/27/25 and 03/06/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 01/20/25 revealed Resident #31 electronically signed the agreement on 01/23/25. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or had been able to view an audio/visual recorded video that details this agreement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete appropriate hand hygiene during medication administration and to maintain contact isolation precautions while in a resident's room with clostridium difficile. This affected two residents (#104 and #178) of five sampled for infection control. The facility census was 124. Findings include: 1. Review of Resident #104's medical record revealed an admission date of 12/24/24 and diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage, chronic pancreatitis, anemia, pneumonitis due to inhalation of food or vomit, tracheostomy status, and gastrostomy status. Review of Resident #104's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Further review revealed the resident was receiving enteral feedings via a gastrostomy tube. Review of Resident #104's orders revealed an order for the resident to be on enhanced barrier precautions (due to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure residents was free from physical and sexual abuse. This affected two residents (#57, #61) of four residents reviewed for abuse. The facility in-house census was 110. Findings included: 1. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, heart failure peripheral vascular disease, anemia, and mental disorder. Review of Resident #61's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact and he had one to three days of other behavioral symptoms not directed towards others. Review of Resident #61's orders and medication administration records dated 02/2024 revealed on 02/08/24 new orders were added to have two staff with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner and failed to ensure food preparation equipment was clean. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility also failed to ensure two residents (#32 and #62)'s personal refrigerators were kept clean and at an appropriate temperature and failed to ensure four residents (#10, #33, #62, and #81)'s personal refrigerator temperatures were logged for safety. The facility census was 97. Findings included: 1. Observation on 01/02/24 at 8:09 A.M. revealed the onion powder and ground cinnamon containers were not closed properly. Observation on 01/03/24 at 9:15 A.M. revealed the onion powder, ground cinnamon, garlic powder, and lemon pepper seasoning salt containers were not closed properly. Interview on 01/03/24 at 10:10 A.M. with [NAME] #192 verified the spice container noted above were open,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 97 residents residing in the facility. Findings included: Observation on 01/02/24 at 9:20 A.M. of the facility dumpster/compactor revealed trash on the ground around the dumpster/compactor. The trash included milk cartons, straws, lids, rubber gloves and a used depends. Interview on 01/02/24 at 9:22 A.M. with State Tested Nursing Assistant (STNA) #131 verified the debris on the ground around the dumpster/compactor and that it should not be there. Review of the facility policy titled, Environment, (revised 09/2017), revealed all trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. Review of the facility policy titled, Disposal of Garbage and Refuse, (reviewed/revised 01/01/22), revealed refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Surrounding area shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident showing signs of Covid-19 was promptly identified, tested, and placed in transmission based precautions (TBP's) for Covid-19 when symptoms originated, failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a room of another resident who was on TBP's for being positive for Covid-19, failed to timely identify and place a third resident in TBP's who had a multi-drug resistant organism in his urine, and failed to ensure sharps (syringes and vacutainers needles) were properly disposed of inside of sharps containers so the needles could not be easily retrieved. This affected three residents (#21, #72, and #82) of three residents reviewed for infections (two for Covid-19 and one for urinary tract infections) and had the potential to review all residents that resided in the facility. Findings include: 1. A review of Resident #21's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review the facility failed to ensure the noise levels were not too loud for Resident #82 and failed to ensure the walls were in good repair for Resident #46, #60, and #192. This affected four residents (Resident #82, #46, #60, #192) of five residents reviewed for environment. The facility census was 97. Findings include: Observation on 01/02/24 at 10:21 A.M. revealed the wall in Resident #46's room had a eight-inch area of wall which had been patched but not painted. Interview on 01/02/24 at 3:09 P.M. with Resident #82 revealed the facility is too loud because another resident keeps a television turned up and Resident #82 has sensitive hearing. Resident #82 stated she could not keep her door closed, and the other resident did not have to turn the television down and declined to wear hearing aids. Observation on 01/03/24 at 8:46 A.M. revealed a ceiling at the foot of Resident #192's bed by the window had a brown-stained tile and there were four quarter-sized holes in the wall in the middle of the room. During a tour with Maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of medication error reports, review of staff education reports, resident interview, and staff interview, the facility failed to ensure residents only received medications ordered and intended for them, medications were administered in accordance with professional standards, and medications were administered within appropriate time frames set forth by the physician's orders. This affected 11 residents (#12, #17, #38, #46, #54, #60, #63, #64, #70, #191, and #192) who were identified from a review of one medication error report. Findings include: 1. A review of Resident #38's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, Parkinson's disease, schizophrenia, bipolar disorder, and hyperlipidemia. A review of Resident #38's physician's orders revealed the resident had an order to receive Atorvastatin 40 milligrams (mg) by mouth (po) at bedtime (hs) for hyperlipidemia. His orders included some psychotropic medications such…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility documentation review, interview, and facility policy review, the facility failed to provide evidence all food was temperature checked prior to serving to confirm food had reached a safe cooking temperature. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility census was 97. Findings include: Review of the Service Line Checklists, dated 12/01/23 to 12/31/23, revealed there were no documented food temperatures on 12/15/23 for breakfast and lunch (prior to service to the residents) and no documented food temperatures on 12/19/23 for lunch. Interview on 01/03/24 at 9:50 A.M. with Dietary Manager #191 verified there was no evidence to support food temperatures were assessed for breakfast and lunch on 12/15/23 and for lunch on 12/19/23. He verified that without checking the temperatures of food, there would be no way to confirm it had reached or was maintained at a safe temperature for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility's week at a glance menu, menus posted in the dining areas, review of the facility's daily newsletter, resident interview, and staff interview, the facility failed to ensure residents were informed of all alternate meals that were made available to them to allow them to make informed choices about the food they wanted to eat with each meal. This had the potential to affect all but six residents (Resident #1, #23, #28, #29, #39, and #198) who the facility identified as receiving nothing by mouth (NPO) and did not receive any food from the kitchen. Findings include: On 01/03/24 at 7:59 A.M., an interview with Resident #43 revealed he had food complaints when interviewed during the annual survey. He felt the food could be better and did not like what was always offered by the facility. He questioned whether the facility was required to offer an alternate meal, in addition to the main meal that was served for each of the three meals they received. He stated he often asked for an alternate to what was being served but there was only so many hot dogs you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the probate court local rules of practice, and interview the facility failed to ensure a resident had a legal guardian when the resident no longer had the ability to maintain capacity. This affected one resident (#7) of two residents reviewed for advance directives. Findings included: Record review revealed Resident #7 was admitted to the facility initially on [DATE] with diagnoses including cognitive communication deficit (added [DATE]), intellectual disabilities (added [DATE]), dementia with mild psychotic disturbance (added [DATE]), major depression, bipolar, anxiety, chronic obstructive pulmonary disease, multiple sclerosis, chronic respiratory failure with hypoxia, asthma, hemiplegia, peripheral vascular disease, plasma-protein metabolism, calculus of gallbladder, spinal stenosis, wedge compression fracture of second lumbar vertebra, nontoxic single thyroid nodule, constipation, contracture of right upper arm, dysphagia, hypertensive heart, gout, hyperlipidemia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was afforded the right to choose how often they bathed and received the type of bathing activity they preferred. This affected one resident (#83) of two residents reviewed for choices. Findings include: A review of Resident #83's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, need for assistance with personal care, and major depressive disorder. A review of Resident #83's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven day assessment period. She had a functional limitation in her range of motion of her bilateral lower extremities. A partial/ moderate assist was needed with showers/ bathing. A review of Resident #83's care plans revealed she had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of resident financial records and staff interview, the facility failed to notify a resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person, and that, if the amount in the account, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected one of six residents whose financial records were reviewed (#59). The facility handled the funds for 62 residents. The facility census was 97. Findings include: Review of the financial records for Resident #59 revealed the facility managed her funds. Review of a statement landscape revealed the balance in the resident's account had been greater than $1800.00 since 05/31/23. On 05/31/23 the balance was $1819.35. The current balance in the account was $1920.74. Interview with Business Office Manager #135 on 01/10/24 at 9:04 A.M. confirmed Resident #59 received Medicaid benefits. She further revealed Resident #59's power of attorney was sent a letter on 06/16/23 notifying her that the balance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, interview, and facility policy review, the facility failed to ensure a resident's advanced directives were clear and consistent. This affected one resident (#25) of two residents reviewed for advanced directives. The facility census was 97. Findings included: Review of Resident #25's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute kidney failure, type two diabetes with diabetic neuropathy, morbid (severe) obesity due to excess calories, and unsteadiness on feet. Review of Resident #25's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed she was cognitively intact. Review of Resident #25's electronic medical record face sheet revealed she was a full resuscitation in case of an emergency for her advanced directives. Review of Resident #25's physician order, dated [DATE], identified she was a full resuscitation. Review of Resident #25's plan of care, dated [DATE], revealed her advanced directives were Do Not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of self-reported incident (SRI), review of grievance/concern log, interviews, and policy review the facility failed to resolve a resident's grievances. This affected one resident (#65) of two residents reviewed for personal property. Finding include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, paraplegia, atrial fibrillation, pressure ulcer, heart failure, neuromuscular dysfunction of the bladder, and chronic pain. Interview on 01/02/24 at 9:39 A.M., with Resident #65 revealed someone had stolen $60.00 the first part of December (2023) out of his room while he was at an appointment. The resident also reported his transfer board was missing as well. He had to buy a new transfer board to leave the facility for Christmas due to the facility couldn't find his and the therapy would not let him borrow one from the facility. The facility had completed an investigation regarding the stolen money; however, they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the resident or their representative was provided with a written summary of the baseline care plan. This affected one residents (#88) of 27 sampled residents. The facility census was 97. Findings include: Review of the closed medical record for Resident #88 revealed an admission date of 09/29/23. The resident had diagnoses including malignant neoplasm of the prostate, liver, colon, and bone. He went home on [DATE] but was readmitted on [DATE] as he was unable to care for himself at home. He remained at the facility until 11/20/23, when he was transferred to the hospital. He did not return to the facility. Record review revealed a care plan meeting was held on 10/02/23 with the resident and his daughter. There was a section of the care plan meeting form to indicate who a copy of the care plan was provided to. It stated upon request. An additional care plan meeting was held on 10/19/23 with the resident. There was a section of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the concern log, review of invoice, observation, and interview the facility failed to ensure a resident had a comprehensive plan of care for vision. This affected one resident (#70) of two residents reviewed for sensory needs. Findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit. Review of the grievance/concern log dated 02/23/23 and 06/07/23 revealed Resident #70's glasses were missing. The resolution on 02/23/23 indicated the glasses would be replaced. There was no documentation regarding the resolution of resident's missing glasses for 06/07/23. Review of Resident #70's vision note dated 03/07/23 revealed the resident had 20/30 vision in bilateral eyes and required glasses. There was an additional note to encourage the resident to wear the glasses part-time for reading. Review of Resident #70's eye glass invoice dated 03/07/23 revealed the resident received a pink…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to revise comprehensive care plans and failed to have quarterly care conferences. This affected three residents (#18, #65, and #70) of four residents reviewed for care planning. The facility census was 97. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, atherosclerotic heart disease, congestive heart failure, and type II diabetes. Review of a quarterly minimum data set (MDS) assessment completed on 06/06/23 revealed Resident #18 had intact cognition and had no behaviors. Review of an assessment titled Care Plan Conference Summary revealed Resident #18 had a care conference on 12/08/22, then had a care conference on 07/27/23. Review of the MDS schedule revealed Resident #18 had a quarterly MDS on 12/02/22, a quarterly MDS on 03/03/23, a quarterly MDS on 06/02/23, a quarterly MDS on 06/06/23, a discharge MDS on 07/03/23, an annual MDS on 08/23/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the care plan, and resident choice, in the areas of orthopedic follow up services, hospice services, and specialty physician consult services. This affected three residents (#26, #80, and #191) of 27 sampled residents. The facility census was 97. Findings include: 1. Review of the medical record for Resident #80 revealed an admission date of 09/27/23 with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. A Minimum Data Set assessment completed 10/01/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. It indicated the resident had no functional limitation in range of motion and required only supervision or touching assistance for sit to stand, chair to bed, toilet transfer, and walking 10 feet. It indicated a fall history but no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to arrange an audiology consult per physician's orders for a resident who was hard of hearing. This affected one resident (#30) of two residents reviewed for communication. The facility census was 97. Findings include: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hyperlipidemia, congestive heart failure, and conductive hearing loss. Review of a care plan dated 08/16/23 revealed Resident #30 was at risk for impaired communication related to hard of hearing and interventions included audiology referral as needed. Review of orders revealed an order from 12/11/23 to please schedule audiology exam dx (diagnosis): hearing loss. Review of a progress note from 12/11/23 by Physician #303 revealed Resident #30 was seen regarding complaints of bilateral hearing loss with a plan of getting a consult for an audiology exam. Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure pressure ulcer treatments were administered as ordered. This affected one resident (#65) of two reviewed for pressure ulcers. The facility census was 97. Findings included: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, Stage 4 pressure ulcers (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) to left and right buttocks, paraplegia, and heart failure. Review of the wound center note dated 12/18/23 revealed the resident would return in three weeks (01/08/24). Review of Nurse Practitioner (NP) note dated 12/27/23 revealed the resident reported he would not be going to the wound center for three weeks due to the holidays fell on Monday, which was his scheduled day. The resident reported he would like…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and policy review the facility failed to ensure suprapubic catheter treatments and antibiotics were administered per order. This affected one resident (#65) of one resident reviewed for urinary catheter/urinary tract infection. Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder, paraplegia, pressure ulcers, and heart failure. Review of Resident #65's pertinent charting for infections dated 12/31/23 and 01/01/24 revealed the resident had completed antibiotic (Clindamycin) regimen and was still having pain and redness around catheter site. New antibiotic being ordered. Review of Resident #65's current orders revealed on 12/21/23 a new order was written to wash suprapubic catheter site with soap and water, pat dry, apply split drain gauze and change daily. There was no evidence a new antibiotic order was written after the resident finished the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical record review, policy review, and staff interview, the facility failed to evaluate a resident's decline in intake to ensure the resident maintained acceptable parameters of nutritional status, such as body weight. This affected one resident (#80) of four residents reviewed for nutritional status. The facility census was 97. Findings include: Review of the medical record for Resident #80 revealed an admission date of 09/27/23 with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. A Minimum Data Set (MDS) assessment completed 10/01/23 documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. It indicated the resident was independent with eating. It stated the resident was 64 inches tall, weighed 118 pounds, and had no weight changes. The resident was admitted on a regular diet. Review of the plan of care dated 09/28/23 revealed the resident was at risk for altered nutritional status related to age, variable intake, abnormal labs, history of significant weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure a resident received timely respiratory care. This affected one resident (#73) of three residents reviewed for respiratory care. The facility census was 97. Findings include: Review of the medical record for Resident #73 revealed an admission date of 06/03/23 and diagnoses including chronic obstructive pulmonary disease (COPD) and alcoholic cirrhosis of the liver. Review of a Minimum Data Set assessment completed 12/15/23 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition. Review of a nurse practitioner progress note dated 12/26/23 at 1:45 P.M. revealed the resident had recent heart catheterization. He was having some chest pain today with drop in oxygen saturation to 88%. He tells me that his pain is localized right to his left sided chest. He does have a moist cough. He does have some shortness of breath. He does not feel it is heart related. He has a history of heart failure as well as hypertension. Does not appear in any distress.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to schedule a pain management appointment for a resident per physician orders. This affected one resident (#65) of one resident reviewed for pain. Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, chronic pain, right hip pain, low back pain, radiculopathy, lumbar and cervical region, paraplegia, Stage 4 pressure ulcers, and heart failure. Review of Resident #65's pain plan of care dated 10/16/23 revealed the resident had low back, pain, pressure ulcers, right hip pain, myalgia, neuralgia, and polyneuropathy. The resident's intervention included pain management/physician referral. Review of Resident #65's pain assessment dated [DATE] revealed the resident had frequent pain in back and hips that was a constant ache. The pain occasionally affected his sleep and physical activities. Review of the Nurse Practitioner (NP) note dated 12/27/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure a resident who required dialysis services received ordered care. This affected one resident (#197) of one resident reviewed for dialysis. The facility census was 97. Findings include: Review of the medical record for Resident #197 revealed an admission date of 12/19/23 and diagnoses including end stage renal disease, diabetes, and morbid obesity. A Minimum Data Set assessment completed 12/23/23 documented a Brief Interview for Mental Status score of 15, indicating intact cognition. It also documented the resident was on dialysis. Interview with Resident #197 on 01/03/24 at 3:25 P.M. revealed she goes out for dialysis three times weekly on Monday, Wednesday, and Friday. She stated, and it was observed, that she has a port in her chest used for the dialysis treatments. She stated she leaves around 6-6:30 A.M. and returns around 11-11:30 A.M. She confirmed she had went to dialysis on 01/03/24. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, resident record review, and facility policy review, the facility failed to ensure medication regimen review irregularities were reviewed by the physician and Director of Nursing (DON). This affected one resident (#47) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: Review of Resident #47's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, type two diabetes mellitus, acute kidney failure, acute congestive heart failure, constipation, major depressive disorder, and generalized anxiety disorder. Review of Resident #47's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed she was cognitively intact. Review of Resident #47's medication regimen review (MRR), dated for recommendations created between 06/01/23 and 06/23/23, revealed the pharmacy had noted Resident #47 was receiving an antipsychotic, Abilify, to treat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure resident medications were monitored per orders. This affected two residents (#65, #70) of five residents reviewed for medication review. Findings include: 1. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia and heart failure. Review of Resident #65's medication orders dated 10/14/23 and 01/10/24 revealed the resident was receiving Lipitor 40 mg at bedtime for hyperlipidemia. Review of Resident #65's pharmacy review dated 11/27/23 revealed the pharmacist recommended laboratory monitoring for the resident's Lipitor therapy. The physician agreed on 11/29/23 to check lipid panel and liver function test (LFT) every six months. Review of Resident #65's laboratory orders revealed on 12/03/23 staff entered an order for lipid panel and LFT's every six months, however the start date wasn't until 12/04/24 (a year later). Review of Resident #65's laboratory results dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of medication error report, review of drug administration information sheet, staff education sheet, interview, and policy reviews the facility failed to ensure residents were free of significant medication errors. This affected one resident (#191) of one resident reviewed for psychotropic medication review. Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's pertinent charting-change in condition progress note dated 12/29/23, 12/31/23, and 01/02/24 revealed on 12/28/23 the resident received a duplicate medication administered on night shift. No adverse reaction was noted at this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure laboratory tests were obtained per orders. This affected one resident (#191) of one resident reviewed for change of condition. Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's admission history and physical dated 12/17/23 revealed to have follow-up blood work tomorrow and have psychology see her. The resident had been running up and down the hallways. She had currently fallen twice. She was on significant psychotropic medication and just need to clarify, if Depakote to be discontinued. She has a history of ulcerative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's infection control tracking logs, staff interview, and policy review, the facility failed to ensure a resident was not treated with an antibiotic, unless they met criteria for the treatment of an infection. They also failed to ensure a resident treated for a urinary tract infection caused by a multi-drug resistant organism received the appropriate antibiotic the identified organisms were sensitive to. This affected one resident (#21) of two residents reviewed for urinary tract infections (UTI) and one resident (#47) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #21's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included cerebral palsy, benign prostatic hyperplasia, and obstructive and reflux uropathy. A review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make himself understood and was able to understand others, but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, policy review, and staff interview, the facility failed to ensure residents were offered a pneumococcal immunization as appropriate. This affected three of five residents reviewed for immunizations (Residents #80, #21, and #82). The facility census was 97. Findings include: 1. Review of the medical record for Resident #80 revealed an admission date of 09/27/23. There was no evidence the resident had received or been offered a pneumococcal immunization. Interview with the Director of Nursing (DON) on 01/03/24 at 2:23 P.M. confirmed the resident had not had and resident/responsible party had not been offered a pneumococcal immunization. She stated it was offered on 01/03/24 and the daughter wanted her to have one but it had not been provided yet. 2. Review of the medical record for Resident #21 revealed an admission date of 08/10/22. Record review revealed he had received a Prevnar 13 vaccine on 01/26/23. (He was less than 65 when getting this vaccine). There was no evidence he had received a follow up dose of PPSV23 as recommended. Interview with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, policy review, and staff interview, the facility failed to offer COVID-19 vaccines to residents. This affected two residents (#46 and #26) of five residents reviewed for immunizations. The facility census was 97. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 02/07/19. Review of the immunization record revealed it simply stated the resident refused a COVID-19 vaccine. However, there was no documented evidence of education provided regarding the vaccine or a signed declination of the vaccine. Interview with the Director of Nursing on 01/03/24 at 2:23 P.M. confirmed no evidence for Resident #46 of education or signed declination of COVID-19 vaccine. 2. Review of the medical record for Resident #26 revealed an admission date of 07/17/23. Review of the immunization record revealed the resident had received COVID-19 vaccines on 01/18/21 and 06/10/22. There was no evidence the resident was provided with a booster or education regarding a booster vaccine. Interview with the Director of Nursing on 01/03/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, chronic obstructive pulmonary disease, major depressive disorder, pseudobulbar affect (PBA), generalized anxiety disorder, difficulty walking, and muscle weakness. A review of Resident #92's Minimum Data Set (MDS) 3.0 assessments revealed she had an admission MDS assessment completed on 02/18/22. Quarterly MDS assessments had been completed on 04/06/22, 07/01/22 and 10/01/22. The quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. The assessment noted the resident was able to make herself understood and was able to understand others. No behaviors were noted. A review of Resident #92's Care Plan Conference Summary assessments revealed the resident had a care planning conference held on 08/08/22. The Care Plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility self-reported incidents and related investigations, facility policy and procedure review and interview the facility failed to ensure all allegations of abuse and misappropriation were thoroughly investigated. This affected eight residents (Resident #7, #10, #23, #50, #71, #72, #101, and #102) reviewed in 10 facility self-reported incidents. The facility census was 100. Findings include: 1. The following self-reported incidents (SRIs) were reviewed involving Resident #102: a. Self-reported incident (SRI) tracking number 218831 revealed an allegation of misappropriation of medications was made by Resident #102 on 03/09/22. Resident #102 alleged his medications, including Methadone 10 milligrams (mg) and Adderall 20 mg that were scheduled to be given as a scheduled dose on 03/09/22 at 12:00 P.M. and 2:00 P.M. respectively were misappropriated by Licensed Practical Nurse (LPN) #510. The resident denied he received either medication as scheduled. The facility indicated they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility self-reported incident review and related investigation, facility policy and procedure review, review of Controlled Drug Receipt/ Record/Disposition Forms, review of narcotic shift count sheets and interview the facility failed to ensure routine medications were provided to residents as ordered and failed to provide adequate pharmaceutical services to meet the needs of each resident. The facility failed to ensure controlled narcotic pain medication was timely/appropriately documented when administered to residents and proper shift to shift reconciliation counts of controlled medication were completed to identify any discrepancies in the counts. The facility also failed to ensure medications were available for administration from their contracted pharmacy. This affected three residents (#86, #102 and #110) of three residents reviewed for misappropriation of medication and one resident (#2) of five residents reviewed for unnecessary medication use. Findings include: 1. A review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure pharmacy recommendation were addressed timely. This affected four residents (#2, #21, #39 and #71) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, anxiety, and depression. Review of Resident #2's pharmacy medication reviews from 10/2021 to 10/2022 revealed the pharmacist made recommendations on 10/22/21, 11/23/21, 12/21/21, 01/27/22, 02/25/22, 03/25/22, 04/28/22, 06/30/22, 08/26/22, 09/28/22 and 10/26/22. Further review revealed no evidence the physician addressed the recommendations made during the 10/22/21, 11/23/21, 12/21/22, 03/25/22, 04/28/22, 06/30/22 or 09/28/22 reviews. On 11/03/22 at 3:34 P.M. interview with the Director of Nursing (DON) revealed she was not able to find or provide evidence of Resident #2's pharmacy recommendations from 10/22/21, 11/23/21, 12/21/22, 03/25/22, 04/28/22,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure and interview the facility failed to provide timely dental services. This affected five residents (Resident #38, #50, #54, #81, and #92) of six residents reviewed for dental services. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, moderate protein-calorie malnutrition, and essential hypertension. Review of Nursing admission Evaluation, dated 08/18/22 revealed Resident #38 came into the facility with upper and lower dentures. Documentation revealed the resident informed the facility at that time she did not wear her dentures because they did not fit properly. Review of Resident #38's Authorization Form for Ancillary and Medical Services, dated 08/19/22 revealed authorization had been provided for dental services. Review of the admission Minimum Data Set (MDS) 3.0…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, facility policy and procedure review and interview the facility failed to ensure pureed foods were prepared in a sanitary manner to prevent potential contamination and/or food borne illness. This had the potential to affect 10 residents (#1, #33, #51, #59, #62, #71, #73, #76, #106 and #310) of 10 residents identified by the facility to receive pureed foods. The facility census was 100. Findings include: On 11/01/22 at 9:00 A.M. Dietary Aide (DA) #157 was observed preparing pureed foods. After preparing brussels sprout puree, DA #157 washed the puree processor in the facility dishwasher. Once the processor came out of the dishwasher, DA #157 used her bare hands to reassemble the inner workings of the processor. She then put pork into the processor before the processor was dry and proceeded to process the pork. After preparing the pork puree, DA #157 washed the puree processor in the facility dishwasher. She then used gloved hands at this time to reassemble the inner workings of the processor. DA #157 then placed potatoes into the processor before the processor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #38's advance directives/code status was consistent between the paper (hard) chart and the electronic health record (EHR). This affected one resident (#38) of 32 residents reviewed for advanced directive. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, dysphagia, moderate protein-calorie malnutrition and essential hypertension. Review of Resident #38's paper/hard chart revealed, effective [DATE] an advanced directive indicating the resident was a Full Code with cardiopulmonary resuscitation (CPR) desired. Review of Resident #38's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident was cognitively intact. Review of Resident #38's electronic health record revealed an advanced directive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a beneficiary protection notification review form and interview the facility failed to ensure Resident #41 was provided an appropriate liability notice when discontinued/cut from Medicare Part-A services with days remaining. This affected one resident (#41) of two residents reviewed for liability notices who remained in the facility. Findings include: Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, apraxia, lupus, pressure ulcer of right hip, peripheral vascular disease, pseudobulbar affect, Vitamin D and Vitamin B12 deficiency, depression, anemia, hyperlipidemia, history of malignant neoplasm of the testis, alcohol abuse, hypertension, atrial fibrillation, cognitive communication deficit, and insomnia. Review of Resident #41's undated Beneficiary Protection Notification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility self-reported incident, facility policy and procedure review and interview the facility failed to ensure Resident #50 was not forced to receive care against her wishes resulting in an allegation of rough care and the resident sustaining minor skin alterations. This affected one resident (#50) of three residents reviewed for physical abuse. Findings include: Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including anxiety, major depression, bipolar, heart disease, and muscle weakness. Review of Resident #50's plan of care, dated 04/26/22 revealed the resident had potential to be physically aggressive or agitated related to anger, depression, history of harm to others, and poor impulse control. Interventions included to analyze times of days, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility Self-Reported Incidents (SRIs) and related investigation, review of controlled drug records/disposition forms, review of an employee personnel file, facility policy and procedure review and staff interview the facility failed to ensure residents were free from misappropriation of controlled (narcotic) medications. This affected two residents (#86 and #110) of three residents reviewed for misappropriation of medication. Findings include: 1. A review of Resident #86's closed medical record revealed the resident was originally admitted to the facility on [DATE] with a readmission date of 07/08/22. The resident had diagnoses including a left femoral neck fracture (hip fracture), low back pain, and the presence of bilateral artificial hip joints. Record review revealed the resident was discharged home on [DATE]. A review of Resident #86's admission Minimum Data Set 3.0 (MDS) assessment, dated 07/14/22 revealed the resident did not have any communication issues as he was able…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure residents and/or their representatives were provided with a transfer notice as required and failed to ensure the State Ombudsman was notified of facility initiated transfers/discharges. This affected three resident (#75, #52 and #109) of four residents reviewed for hospitalization and discharge. Findings include: 1. Medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease stage 4, and urinary tract infection (UTI). The resident was hospitalized from [DATE] to 10/10/22 for diagnoses of small bowel obstruction, UTI, abscess of chest wall, and high troponin level. Further review of the resident's electronic medical record and paper/hard chart revealed no evidence a transfer/discharge form was completed and given or sent to the resident/resident representative. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #109 was provided a bed hold notice upon transfer to the hospital. This affected one resident (#109) of three residents reviewed for hospitalization. Findings include: Record review revealed Resident #109 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #109 had diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, absence of part of a lung, sacrolitis, paraplegia, pneumonia, Parkinson's disease, pressure ulcers, cognitive communication deficit, depression, restless leg syndrome, overactive bladder, muscle weakness, anxiety, hyperlipidemia, and lumbago with sciatica. Review of Resident #109's nursing note, dated 09/25/22 revealed the resident's oxygen saturation reading was 70 percent. No other signs of hypoxia, respirations even and unlabored. The resident was alert and oriented times four (person,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) documentation was accurate to reflect the resident's cumulative diagnoses and updated following a change in mental health diagnoses. This affected one resident (#77) of two residents reviewed for PASARR. Findings include: Review of Resident #77's medical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, essential hypertension, chronic obstructive pulmonary disease, and tremors. Review of Resident #77's PASARR, dated 08/02/22 revealed under Section E, subsection 1.: Indications of Serious Mental Illness the boxes beside panic or other severe anxiety disorder and personality disorder were marked with an X. The box beside of mood disorder was not marked with an X even though Resident #77 had a depression and bipolar disorder diagnosis. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for Resident #39 prior to admission. This affected one resident (#39) of two residents reviewed for PASARR. Findings include: Record review revealed Resident #39 was admitted to the facility originally on 06/23/22 and re-admitted on [DATE] with diagnoses including dementia with moderate behavioral disturbance, major depression, anxiety, psychosis, and insomnia. Review of Resident #39's progress notes revealed the resident was admitted on [DATE] and transferred back out to the psychiatric hospital a few hours later. Review of Resident #39's paper/hard chart and electronic medical record revealed no evidence a PASARR was completed for the 06/23/22 admission or the 07/11/22 re-admission. Review of Resident #39's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/19/22 revealed the resident was not considered for Level II services through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure comprehensive and individualized care plans were developed and implemented for all residents. This affected three residents (#38, #54, and #77) of 36 sampled residents reviewed for care planning. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, moderate protein-calorie malnutrition, and essential hypertension. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 08/25/22 revealed Resident #38 was cognitively intact, had no broken or loosely fitting full or partial denture and had no natural teeth or tooth fragments. Review of Resident #38's care plan, dated 08/19/22 revealed a focus area related to the resident's dentures not fitting appropriately. An intervention included to coordinate arrangements for dental care, transportation as needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive, person-centered care plans were accurate to reflect the resident's current status and/or revised to include current interventions for Resident #28 related to pressure ulcers and for Resident #41 related to falls/accident hazards. This affected two residents (#28 and #41) of 36 sampled residents whose care plans were reviewed. Findings include: 1. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of shaft of left humerus, hypertension, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 (out of 15), which indicated intact cognition. There assessment revealed the resident had no behaviors or rejection of care. The MDS 3.0 assessment further revealed Resident #28 required extensive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #39 received the necessary care and weight monitoring as ordered related to a diagnosis of congestive heart failure and failed to ensure Resident #2 had appropriate indication of use of an anti-fungal medication and monitoring. This affected one resident (#2) of one resident reviewed for non-pressure related skin impairment and one resident (#39) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnosis including hypertensive heart disease with heart failure. Review of Resident #39's congestive heart failure plan of care, dated 07/12/22 revealed to monitor vital signs and monitor, document, report to the nurse and physician as needed for any signs and symptoms of congestive heart failure (CHF) such as weight gain and weight monitoring as ordered. Review of Resident #39's physician's orders revealed an order, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents received optometry services timely when needed. This affected two residents (#50 and #92) of four residents reviewed for vision/hearing. Findings include: 1. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a history of a stroke with hemiplegia/ hemiparesis affecting the left non-dominant side, pseudobulbar affect, major depressive disorder, and generalized anxiety disorder. A review of Resident #92's ancillary service consent form revealed the resident consented to receive optometry services from the facility's contracted optometrist while residing in the facility. A review of Resident #92's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed the resident did not have any communication issues and her cognition was moderately impaired. The assessment revealed the resident's vision was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure a thorough and complete pressure ulcer assessment was completed for Resident #28 following a re-admission to the facility and failed to ensure wound treatments were provided as ordered by the physician. This affected one resident (#28) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. Findings include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of shaft of left humerus, hypertension, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 (out of 15), which indicated intact cognition. The assessment revealed the resident had no behaviors or rejection of care. The MDS 3.0 assessment further revealed Resident #28 required extensive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #28 received appropriate services to maintain range of motion/mobility and failed to ensure Resident #38 received restorative services. This affected two residents (#28 and #38) of five residents reviewed for position/range of motion and mobility. Findings include: 1. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of shaft of left humerus, hypertension, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 (out of 15), which indicated intact cognition. The assessment revealed the resident had no behaviors or rejection of care. The MDS further revealed Resident #28 required extensive, two-person assistance with personal hygiene, bed mobility, and transfers. The MDS assessment revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility fall investigations, facility policy and procedure review and interview the facility failed to ensure Resident #92 received the appropriate level of assistance during a transfer and had proper footwear on at the time of the transfer to prevent an avoidable fall. The facility also failed to develop a comprehensive and individualized fall prevention program for Resident #41 and failed to ensure comprehensive fall investigations were completed to identify the root cause of falls so appropriate interventions could be initiated to prevent additional falls from occurring for the resident. This affected two residents (#41 and #92) of four residents reviewed for falls and/or accident hazards. Findings include: 1. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, unsteadiness on her feet, abnormalities of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #79 received adequate and proper care during incontinence care to decrease the resident's risk of developing a urinary tract infection. In addition, the facility failed to timely obtain a urinalysis with reflex culture for Resident #28, who had symptoms of a urinary tract infection, as ordered by the physician. This affected two residents (#28 and #79) of nine residents reviewed for unnecessary medication use or urinary tract infection. Findings include: Review of Resident #79's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including type two diabetes, morbid obesity, systemic lupus and chronic obstructive pulmonary disease. Review of Resident #79's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/24/22 revealed the resident was cognitively intact and always incontinent. On 11/02/22 at 2:10 P.M. State Tested Nursing Assistant (STNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, facility policy and procedure review and interview the facility failed to accurately document Resident #78's enteral (tube) feeding intake to ensure the resident's overall nutritional status was monitored. This affected one resident (#78) of two residents reviewed for nutrition. Findings include: Review of Resident #78's medical record revealed an initial admission date of 07/07/22 with a readmission date of 10/28/22. Resident #78 had diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, dysphagia, and type two diabetes. Review of Resident #78's admission Minimum Data Set (MDS) 3.0 assessment, dated 09/28/22 revealed the resident was cognitively intake and received enteral feeding via a gastrostomy (feeding) tube for nutritional intake. Review of Resident #78's physician's orders revealed an order, dated 10/26/22 for dietary to evaluate calorie intake/tube feedings. Review of Resident #78's physician's order revealed an order, dated 11/03/22 for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure oxygen was delivered at the flow rate ordered by the physician for Resident #38. This affected one resident (#38) of four residents reviewed for respiratory therapy. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, moderate protein-calorie malnutrition, and essential hypertension. Review of Resident #38's physician's orders revealed an order, dated 08/20/22 for oxygen at three liters/minute via a nasal cannula continuously. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 08/25/22 revealed Resident #38 was cognitively intact, had an active diagnosis of respiratory failure and was receiving oxygen prior to admission and while a resident. Review of Resident #38's October and November 2022 Treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure Resident #78 had an appropriate diagnosis for the use of the anti-psychotic medication, Seroquel. This affected one resident (#78) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #78 revealed an admission date of 09/22/22 with diagnoses including dementia without behavioral disturbance, major depressive disorder, anxiety, diabetes mellitus, muscle weakness, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/28/22 revealed Resident #78's Brief Interview for Mental Status (BIMS) score was 14 (out of 15), which indicated intact cognition. The assessment revealed the resident did not have any hallucinations, delusions, physical or verbal behaviors, or rejection of care. The resident required total, two-person physical assistance with bed mobility, transfers, toileting, and dressing. Review of the resident's plan of care reflected the use of anti-psychotic medication. Review of a physician's order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 6.25% and included two medication errors of 32 medication administration opportunities. This affected one resident (#98) of three residents observed for medication administration. Findings include: A review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic congestive heart failure, hypertensive heart disease, history of a myocardial infarction (heart attack), and arthropathy (any disease of the joints such as arthritis). On 11/02/22 at 8:27 A.M., a medication administration observation was made for Resident #98's morning medication administration. The resident's medications were administered by Registered Nurse (RN) #90. During the observation, the resident was administered a Coreg (a beta blocker used in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #38 received timely diagnostic services. This affected one resident (#38) of two residents reviewed for nutrition. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, dysphagia, moderate protein-calorie malnutrition, and essential hypertension. Review of Resident #38's care plan, dated 08/19/22 revealed a focus related to the resident having a potential for nutritional deficits related to therapeutic and mechanically altered diet, abnormal labs, and potential for weight fluctuations related to fluid, variable intake. The goal was for Resident #38 to maintain an adequate nutritional status as evidenced by diet tolerance and adequate intakes for weight stability without significant change. An interventions to meet this goals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to implement an effective infection control program including the timely implementation of contact isolation for Resident #92 who was diagnosed with a urinary tract infection that was positive for Methicillin Resistant Staphylococcus Aureus to prevent the spread of infection. This affected one resident (#92) of nine residents reviewed for unnecessary medication use or urinary tract infections. Findings include: A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a history of a stroke with hemiplegia and hemiparesis affecting the left non-dominant side, neuromuscular dysfunction of the bladder, urinary tract infection (UTI), and Methicillin Resistant Staphylococcus Aureus (MRSA) infection. A review of Resident #92's nursing progress notes revealed a nurse's note, dated 10/27/22 that revealed the resident was complaining of a burning sensation at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to develop and implement an effective antibiotic stewardship program as part of their infection control program to ensure the appropriate use of antibiotic treatment for infections. This affected three residents (#2, #79 and #77) of nine residents reviewed for unnecessary antibiotic use or urinary tract infections. Findings include: 1. Record review for Resident #77 revealed the resident had diagnoses including acute infections, bipolar disorder, major depressive disorder, anxiety disorder, essential hypertension, chronic obstructive pulmonary disease, and tremors. Review of acute care documentation, dated 08/16/22 revealed Resident #77 had a urine culture positive for pseudomonas, E. coli, candida with susceptibility pending. The acute care facility recommended to change the antibiotic, Rocephin to Cefepime and add Diflucan for seven days with renal dose adjustment following the first dose. Record review revealed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #52's call signal device was in proper working order. This affected one resident (#52) of six residents reviewed for physical environment. Findings include: Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, benign prostatic hyperplasia, and generalized muscle weakness. Review of Resident #52's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/02/22 revealed the resident was cognitively impaired and required supervision with (staff) set up assistance only for eating. On 10/31/22 at 2:30 P.M. observation of Resident #52's call signal device revealed the device did not activate when the button was pushed. On 11/02/22 at 8:50 A.M. observation revealed Resident #52's call signal device did activate when the button was pushed. The resident was observed to attempt to activate the call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.